Provider Demographics
NPI:1619636370
Name:WIETIG, DANIELLE LUCILLE (LPN)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:LUCILLE
Last Name:WIETIG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:DANIELLE
Other - Middle Name:LUCILLE
Other - Last Name:RYDZYNSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:116 HAMLIN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-1607
Mailing Address - Country:US
Mailing Address - Phone:716-430-0576
Mailing Address - Fax:
Practice Address - Street 1:116 HAMLIN AVE
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-1607
Practice Address - Country:US
Practice Address - Phone:716-430-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321020-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse